The combination of speed, strength, endurance, and technical skill places high demands on the
physical performance of football players. However, these demands often come with an increased risk of injury, which cannot always be completely avoided due to many uncontrollable factors. Nevertheless, the risk of injuries can be reduced through appropriate preventive measures. It is important to develop strategies and implement measures based on scientific knowledge and evidence-based methods.
Significant progress has been made in the field of injury prevention in football over the past three decades. Numerous research studies have been conducted, ranging from the sequence of research steps and the investigation of injury causes to the development and implementation of corresponding prevention programs. Van Mechelen et al. [1] developed a fundamental conceptual 4-step protocol for the prevention of sports injuries in 1992, which has since been further developed and adapted for many sports and injuries. Finch [2] expanded this model with two additional steps and formulated the TRIPP model, which aims to facilitate the transfer of research findings into injury prevention practice. Padua et al. [3] further supplemented this model with two additional steps focusing on the development and implementation of prevention programs. Meeuwisse [4] developed the dynamic, multifactorial model of the etiology of sports injuries to consider a variety of external and internal factors that can influence the risk of injury. To understand the injury-triggering event and the combination of factors that lead to an injury, Bahr & Krosshaug [5] developed a model that takes these events into account.
Using these models, multimodal injury prevention programs for the lower extremities have been developed. There is extensive evidence supporting the effectiveness of movement interventions in the form of neuromuscular training as a warm-up program to reduce football-related injuries in both genders, all age groups, and different skill levels. Examples of effective programs include the FIFA 11+ program [6], the Knee Control Program [7], and the Prevent Injury and Enhance Performance Program [8]. Specific selected exercises such as the Nordic Hamstring Curl (NHC) [9] or the Copenhagen Plank [10] also show a positive effect on reducing injuries. Despite the existence of evidence-based programs, there is often inadequate implementation in practice. This is often due to the required time commitment, associated costs, or lack of coaching staff. Careful adherence and consistent implementation by the coaching team also play a crucial role. Programs are often irregularly carried out or only parts or modified programs are applied. Reasons for this may include a lack of knowledge or insufficient experience in implementing and correctly executing these programs, as well as the complexity of the exercises [11].
8-Step Model
In Figure 1, an 8-step model is presented that is intended to help better understand the various components and steps of a successful injury prevention system, starting from the identification of sport-specific requirements to knowledge transfer and program effectiveness assessment.
Individualization
A crucial factor for the success of injury prevention programs lies in the individual alignment during the development and implementation of corresponding measures. It is important to differentiate between primary, secondary, and tertiary prevention in the sports context. Primary prevention aims to prevent initial injuries. Secondary prevention involves the timely diagnosis and treatment of minor physical complaints or injuries with the goal of reducing severity. Tertiary prevention focuses on the rehabilitation of injuries with longer absence from training or competition and minimizing the risk of recurrent injuries [12].
When designing injury prevention programs, it is essential to differentiate between healthy players without injuries and players with injuries or a history of injuries. For athletes with previous injuries, it is important to identify specific risk factors that could lead to a recurrent injury. Additionally, potential neuromuscular and sensorimotor deficits that may have resulted from previous injuries should be considered. This can be done through written questionnaires, verbal interviews, or through assessments and screenings (e.g., FMS). Healthy athletes require a less conservative and more progressive approach. The prophylactic application of standardized prehab/rehab protocols is usually not sufficient for them. Healthy athletes typically adapt more quickly to demands and require appropriate progressions to avoid plateaus. The intensity threshold and neuromuscular challenge to achieve the desired adaptation will be higher in healthy athletes than in recently injured players. There may also be differences in motivation, as healthy athletes may be less intrinsically motivated to reduce pain and other symptoms compared to recently injured players. To ensure long-term compliance in healthy players, greater variation in exercises will be required to avoid training monotony.
Nutrition also plays an important role in the injury prevention process and should be adjusted accordingly. Proper nutrition not only helps supply the body’s energy stores and adjust to the demands of the sport but also supports the body’s natural healing and recovery processes. The physiological demands on athletes vary not only between different sports but also within a sport depending on position (e. g., goalkeeper vs. forward). Considering the individual weight goals of athletes, it is clear that generalized nutrition strategies are inadequate. These should be individually tailored based on actual training intensity, volume, and level to allow for precise alignment of energy intake and energy needs. Additionally, it is important to ensure adequate fluid intake before, during, and after training or a game. A fluid deficit at the start of a game can significantly impair performance and increase the risk of hyperthermia [13].
Planning the Implementation of an Injury Prevention Program
The selection of exercises, training frequency, timing, intensity, and volume play a crucial role in the design and subsequent implementation of injury prevention programs. The programs should include various exercises in the areas of endurance, strength, plyometrics, speed, agility, and flexibility. In addition to these areas, prevention programs may include exercises to improve core stability, balance, and proprioception [14, 15]. An overall protective effect of endurance training is that athletes become more resilient to neuromuscular fatigue. This is particularly important as injuries often occur in the final phase of a game when athletes are already fatigued. Adequate strength training increases the load tolerance of the musculoskeletal system to the microtraumas that occur in training or games, leading to faster recovery. When selecting appropriate exercises in strength training, factors such as range of motion, speed of movement, and contraction form should be considered based on the respective injury mechanisms. A commonly used exercise, for example, is the Nordic Hamstring Curl (NHC). Eccentric training improves the muscle’s ability to absorb more energy before reaching muscle failure [16].
However, in this exercise, the proximally stressed muscles remain in a relatively constant position. Relevant hamstring injuries mainly occur during the terminal swing and early support phases of running. A suitable complement could be the Romanian Deadlift, as it also engages the proximal part of the hamstrings. Plyometric training not only improves explosive power but also has a preventive character. The focus should be on correct technique and mechanics in landing, jumping, and change of direction movements [17]. However, to prevent injuries, sport-specific and speed-oriented training is also required. A large portion of hamstring injuries occur during sprinting, so training at maximum speed should be given more attention. It is recommended to integrate sprint training at least once a week, reaching < 90 % of individual maximum speed [18].
As part of the training program, athletes should apply appropriate recovery strategies. Active recovery measures usually consist of aerobic training, which can be performed through various methods such as cycling, jogging, aqua jogging, or swimming. Active recovery is often seen as more beneficial compared to passive recovery due to improved blood flow and the elimination of metabolic waste products through increased oxygen supply. Among passive recovery methods, sleep is generally considered the most important factor. Inadequate sleep or poor sleep quality not only affect performance but also increase the risk of injury and negatively impact recovery after training or games. Athletes who sleep ≤ 7 hours per night over an extended period already have a 1.7 times higher risk of experiencing an injury compared to athletes who sleep ≥ 8 hours per night [19, 20].
Periodization
The integration of an injury prevention program into the weekly and daily training cycle can be a significant challenge but also offers many opportunities. Figure 2 illustrates a possible integration of injury prevention measures into a microcycle of one week. Prevention measures can be integrated into both the warm-up and cool-down, depending on the focus of the exercises or the training session [21]. An advantage of integrating into the warm-up or cool-down with the team is that the exercises are performed under the supervision of a coach, ensuring a higher quality of execution. Additionally, training takes place in a group setting and generally enhances athletes’ motivation. Likewise, appropriate prevention exercises can be integrated into the athletes’ individual strength training, where the coach may not be able to make corrections during execution. Integrating preventive exercises into the coach-supervised strength training could provide an additional opportunity to ensure the necessary individualization while maintaining high quality. Injury prevention training should ideally be conducted 2 – 3 times per week, preferably at the beginning and middle of the week. Performing isolated eccentric training at the end of the week could negatively impact game performance due to the regeneration time of up to 72 hours. Eccentric training on the day after the game results in significantly fewer microtraumas than performing it on the third day after the game [22].
Conclusion
Significant progress has been made in injury prevention research and application over the past 30 years. However, translating theoretical knowledge into practice remains a major challenge for all involved, yet it also presents one of the most promising opportunities for the future of football medicine. To successfully integrate injury prevention into clubs and teams, a systematic approach and a comprehensive understanding of each step are required. Further research, particularly on parameters such as exercise selection, volume, intensity, and periodization, is necessary to adapt programs to different contexts. Established programs that already exist and have been successfully tested can be easily implemented by amateur teams with limited training time. Professional teams, on the other hand, require a variety of evidence-based exercises with appropriate progressions and variations. Injury prevention should not be viewed in isolation from performance enhancement, as they are closely linked. The foundation for this should be individualization, distinguishing between athletes with or without a history of injury. The success of injury prevention programs depends on regular implementation. Therefore, measures to reduce injuries should be an integral part of football training. This, in turn, requires a high level of willingness to implement on the part of the players, coaching staff, and the club.
Literature
[1] Van Mechelen, W., Hlobil, H., & Kemper, H. C. G. (1992). Incidence, Severity, Aetiology and Prevention of Sports Injuries: A Review of Concepts. Sports Medicine, 14(2), 82–99.
[2] Finch, C. (2006). A new framework for research leading to sports injury prevention. Journal of Science and Medicine in Sport, 9(1–2), 3–9.
[3] Padua, D. A., Frank, B., Donaldson, A., De La Motte, S., Cameron, K. L., Beutler, A. I., DiStefano, L. J., & Marshall, S. W. (2014). Seven Steps for Developing and Implementing a Preventive Training Program. Clinics in Sports Medicine, 33(4), 615–632.
[4] Meeuwisse, W. H. (1994). Assessing Causation in Sport Injury: A Multifactorial Model. Clinical Journal of Sport Medicine, 4(3), 166–170.
[5] Bahr, R., & Krosshaug, T. (2005). Understanding injury mechanisms: A key component of preventing injuries in sport. British Journal of Sports Medicine, 39(6), 324–329.
[6] Thorborg, K., Krommes, K. K., Esteve, E., Clausen, M. B., Bartels, E. M., & Rathleff, M. S. (2017). Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: A systematic review and meta-analysis of the FIFA 11 and 11+ programmes. British Journal of Sports Medicine, 51(7), 562–571.
[7] Walden, M., Atroshi, I., Magnusson, H., Wagner, P., & Hagglund, M. (2012). Prevention of acute knee injuries in adolescent female football players: Cluster randomised controlled trial. BMJ, 344(may03 1), e3042–e3042.
[8] Gilchrist, J., Mandelbaum, B. R., Melancon, H., Ryan, G. W., Silvers, H. J., Griffin, L. Y., Watanabe, D. S., Dick, R. W., & Dvorak, J. (2008). A Randomized Controlled Trial to Prevent Noncontact Anterior Cruciate Ligament Injury in Female Collegiate Soccer Players. The American Journal of Sports Medicine, 36(8), 1476–1483.
[9] Petersen, J., Thorborg, K., Nielsen, M. B., Budtz-Jørgensen, E., & Hölmich, P. (2011). Preventive Effect of Eccentric Training on Acute Hamstring Injuries in Men’s Soccer: A Cluster-Randomized Controlled Trial. The American Journal of Sports Medicine, 39(11), 2296–2303.
[10] Harøy, J., Clarsen, B., Wiger, E. G., Øyen, M. G., Serner, A., Thorborg, K., Hölmich, P., Andersen, T. E., & Bahr, R. (2019). The Adductor Strengthening Programme prevents groin problems among male football players: A cluster-randomised controlled trial. British Journal of Sports Medicine, 53(3), 150–157.
[11] Minnig, M. C., Hawkinson, L., Root, H. J., Driban, J., DiStefano, L. J., Callahan, L., Ambrose, K. R., Spang, J. T., & Golightly, Y. M. (2022). Barriers and facilitators to the adoption and implementation of evidence-based injury prevention training programmes: A narrative review. BMJ Open Sport & Exercise Medicine, 8(3), e001374.
[12] Kisner, C., & Colby, L. A. (2012). Therapeutic exercise: Foundations and techniques (6th ed). F.A. Davis.
[13] Belval, L. N., Hosokawa, Y., Casa, D. J., Adams, W. M., Armstrong, L. E., Baker, L. B., Burke, L., Cheuvront, S., Chiampas, G., González-Alonso, J., Huggins, R. A., Kavouras, S. A., Lee, E. C., McDermott, B. P., Miller, K., Schlader, Z., Sims, S., Stearns, R. L., Troyanos, C., & Wingo, J. (2019). Practical Hydration Solutions for Sports. Nutrients, 11(7), 1550.
[14] Gallucci, J. (2014). Soccer injury prevention and treatment: A guide to optimal performance for players, parents and coaches. Demos Medical Publishing, LLC.
[15] Meyer, T., Faude, O., & Funten, K. A. der. (2015). Sports medicine for football: Insight from professional football for all levels of play. Meyer & Meyer Sport.
[16] LaStayo, P. C., Woolf, J. M., Lewek, M. D., Snyder-Mackler, L., Reich, T., & Lindstedt, S. L. (2003). Eccentric Muscle Contractions: Their Contribution to Injury, Prevention, Rehabilitation, and Sport. Journal of Orthopaedic & Sports Physical Therapy, 33(10), 557–571.
[17] Bahr, R., & Engebretsen, L. (2009). Sports injury prevention. Wiley-Blackwell.
[18] Edouard, P., Mendiguchia, J., Guex, K., Lahti, J., Prince, C., Samozino, P., & Morin, J.-B. (2023). Sprinting: A key piece of the hamstring injury risk management puzzle. British Journal of Sports Medicine, 57(1), 4–6.
[19] Milewski, M. D., Skaggs, D. L., Bishop, G. A., Pace, J. L., Ibrahim, D. A., Wren, T. A. L., & Barzdukas, A. (2014). Chronic Lack of Sleep is Associated With Increased Sports Injuries in Adolescent Athletes. Journal of Pediatric Orthopaedics, 34(2), 129–133.
[20] Huang, K., & Ihm, J. (2021). Sleep and Injury Risk. Current Sports Medicine Reports, 20(6), 286–290.
[21] Small, K., McNaughton, L., Greig, M., & Lovell, R. (2009). Effect of Timing of Eccentric Hamstring Strengthening Exercises During Soccer Training: Implications for Muscle Fatigability. Journal of Strength and Conditioning Research, 23(4), 1077–1083.
[22] Lovell, R., Whalan, M., Marshall, P. W. M., Sampson, J. A., Siegler, J. C., & Buchheit, M. (2018). Scheduling of eccentric lower limb injury prevention exercises during the soccer micro‐cycle: Which day of the week? Scandinavian Journal of Medicine & Science in Sports, 28(10), 2216–2225.
Autoren
ist Athletik- und Rehatrainer beim österreichischen Bundesligisten WSG Tirol. Der Sportwissenschaftler (M.A.) ist Inhaber der Uefa B-Lizenz und auf das athletische Individualtraining spezialisiert. Zuvor war er mehrere Jahre als Athletiktrainer im Eishockey tätig (Nürnberg Ice Tigers, Deutscher Eishockey-Bund).
